United States Traveler Health Declaration - English

Emergency Submission to Supplement OMB Control Number 0920-0821 in the context of Screening Travelers for Ebola Risk

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1031 can be found here:

Documents and Forms

Document Name Document Type
United States Traveler Health Declaration - English Form and Instruction
United States Traveler Health Declaration - English Attachment A1 United States Traveler Health Declaration - English.doc Form and Instruction

Information Collection (IC) Details

IC Title:	United States Traveler Health Declaration - English	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	United States Traveler Health Declaration - English	Attachment A1 United States Traveler Health Declaration - English.doc	None	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 45,625	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	45,625	45,625
Annual IC Time Burden (Hours)	11,406	11,406
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.